To

CPP Claims Management

D-139 Okhla Industrial Area, Phase 1

New Delhi 110020

NV21021322555
(TO BE PASTED ON THE OUTER SIDE OF THE ENVELOPE IN WHICH YOU WILL SEND YOUR CLAIM DOCUMENTS TO CPP)
 CONSUMER CLAIM FORM

NV21021322555

SRN No : Membership No :

NV21021322555 IM6964282

Name of Membership Holder : Registered Mobile No :

MR Mr Sunil Vishwakarma 9415983252

Have you visited the Brand Authorized Service Centre: Have you got your device repaired:

Yes Yes

Repair Bill Amount:

* Insurer Name :

3480 HDFC

Incident Date :
* Intimation Date:
*

12-Oct-2021 12-Oct-2021

IMEI No :
* Name Mismatch Between Membership and Cancelled Cheque
:
*
`350766960699017
No

I hereby confirm that all the facts stated above and documents are correct and true, to the best of my knowledge. If anything is found
to be incorrect, I agree that the Insurer will have the right to reject my claim.
I agree to all the terms and conditions of my membership as given to me by
CPP India and any conditions imposed by all insurers
associated with them, from whom I may have directly or indirectly procured this insurance.
The quote of benefits and claim I have filed does not guarantee payment or verify eligibility.
Payment of benefits are subject to all terms,
conditions, limitations, and exclusions of the member's contract at time of service.

Signature Here

(PLEASE MAKE SURE YOU SIGN THIS FORM AND PUT INTO YOUR ENVELOPE AS THE COVERING LETTER FOR THE CLAIM DOCUMENTS
YOU ARE SENDING)